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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850343
Report Date: 06/16/2023
Date Signed: 07/11/2023 09:02:13 AM

Document Has Been Signed on 07/11/2023 09:02 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:TERNER HOME 2FACILITY NUMBER:
195850343
ADMINISTRATOR:BAGDASARIAN, SIRANUSHFACILITY TYPE:
740
ADDRESS:7056 MATILIJA AVENUETELEPHONE:
(818) 326-0336
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY: 6CENSUS: DATE:
06/16/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Siranush BagdasarianTIME COMPLETED:
11:30 AM
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Facility Type: RCFE
Application Type: Initial
Capacity: 6
Census (if any clients in care): zero in home
COMP II Participants: Siranush Bagdasarian (Sara)
Interview Method: Telephone interview

On June 16, 2023, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.
SUPERVISORS NAME: Julia Kim
LICENSING EVALUATOR NAME: Dianne Ramos
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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